ATrain Education

 

Continuing Education for Health Professionals

Elders and Their Care

Module 6

Risk for Falls in Elders

More than one-third of people aged 65 and older fall each year, and those who fall once are 2 to 3 times more likely to fall again (Stevens and Sogolow, 2008). Repeated falls significantly limits a person’s ability to remain self-sufficient. Fall injuries are responsible for significant disability, reduced physical function, and loss of independence.

Because falls often cause injuries such as hip fractures and head trauma, they can increase the risk of early death. In the year 2000 direct medical costs for fall injuries in the United States totaled $19 billion. Despite these troubling statistics, studies have shown that preventive interventions can reduce falls (Stevens and Sogolow, 2008).

Facts About Falls

  • One out of 3 adults age 65 and older falls each year.
  • Among those age 65 and older, falls are the leading cause of injury death. They are also the most common cause of nonfatal injuries and hospital admissions for trauma.
  • In 2007 over 18,000 older adults died from unintentional fall injuries.
  • The death rates from falls among older men and women have risen sharply over the past decade.
  • In 2009, 2.2 million nonfatal fall injuries among older adults were treated in emergency departments and more than 581,000 of these patients were hospitalized.
  • In 2000 direct medical costs of falls totaled a little over $19 billion$179 million for fatal falls and $19 billion for nonfatal fall injuries.

Source: CDC, 2011d.

Fall Risk in the Elderly

  • More than 90% of hip fractures are associated with osteoporosis.
  • Nine out of 10 hip fractures in older Americans are the result of a fall.
  • Elders who have a hip fracture are 5% to 20% more likely to die in the first year following that injury than others in this age group.
  • For those living independently before a hip fracture, 15% to 25% will still be in long-term care institutions a year after their fracture.
  • Most falls happen to women in their homes, in the afternoon.

Source: CDC, 2011d.

Falls should not be seen as an inevitable consequence of aging, even though falls do occur more often among older adults and fall risk increases with age. Risk factors can be biologic, behavioral, or environmental (CDC, 2008b):

Biologic Risk Factors

  • Mobility problems due to muscle weakness or balance problems
  • Chronic health conditions such as arthritis and stroke
  • Vision changes and vision loss
  • Loss of sensation in feet or legs

Behavioral Risk Factors

  • Inactivity
  • Medication side effects and/or interactions
  • Alcohol use

Environmental Risk Factors

  • Home and environmental hazards (clutter, poor lighting, etc.)
  • Incorrect size, type, or use of assistive devices (walkers, canes, crutches, etc.)
  • Poorly designed public spaces

Risks Related to Polypharmacy

Polypharmacy is a well-established risk factor for falls in the older adult. In her seminal 1994 study of risk factors associated with falls in elders, Mary Tinetti studied modifiable risk factors and the effects of interventions on the risk of falling among community-dwelling older adults. Physicians, nurse practitioners, and physical therapists examined these risk factors in a control group and an intervention group:

  • Postural hypotension
  • Use of sedatives
  • Use of at least four prescription medications
  • Impairment in arm or leg strength or range of motion
  • Balance
  • Ability to move safely from bed to chair or to the bathtub or toilet (transfer skills)
  • Gait (Tinetti, 1994)

Serotonin-reuptake inhibitors (SSRIs), tricyclic antidepressants, neuroleptic agents, benzodiazepines, anti-convulsants, and anti-arrhythmic medications have been shown to have the strongest link to an increased risk of falling. Others have noted that an increased risk of falls is especially associated with the following classes of medications:

  • Hypnotics
  • Sedatives
  • Analgesics
  • Psychotropics
  • Antihypertensives
  • Laxatives
  • Diuretics (CDC, 2007b)

The purpose of medication review and management is to identify and eliminate medication side effects and interactions, such as dizziness or drowsiness, that can increase the risk of falls. Many older adults are unaware that their daily medications may increase their fall risk. Aging affects the absorption, distribution, metabolism, and elimination of medications. Age can also increase sensitivity to potential side effects (CDC, 2008b).

Older adults may get prescriptions from multiple doctors. Fall risk increases with the total number of prescription and over-the-counter medications. Less well known is that fall risk can increase significantly in the days following a medication change.

Psychoactive medications (drugs that alter brain function) increase fall risk. These include antidepressants, tranquilizers, antipsychotics, anti-anxiety drugs, and sleep medications. Other medications that may cause problems include those prescribed to treat seizure disorders, blood pressure-lowering medications, cholesterol-lowering medications, heart medications, and painkillers (CDC, 2008b).

Drug side effects that can contribute to falling include blurred vision, hypotension leading to dizziness and lightheadedness, sedation, decreased alertness, confusion and impaired judgment, delirium, compromised neuromuscular function, and anxiety. Review and modification of medications by a healthcare provider can frequently reverse or minimize these effects.

Clinicians should regularly review each patient’s medications for potential interactions and side effects that may increase fall risk and, where possible, reduce or eliminate medications or select alternatives. Reducing the number and types of medications, particularly tranquilizers, sleeping pills, and anti-anxiety drugs, can be an effective fall prevention strategy when used alone or as part of a multi-component intervention (CDC, 2007).

Usually two or more risk factors interact to cause a fall (eg, poor balance and low vision). Home or environmental risk factors play a role in about half of all falls (CDC, 2008b). In older clients, the following factors should alert a healthcare provider to the possibility of increased fall risk and trigger a fall prevention assessment and intervention:

  • Agitation/delirium
  • Medication timing and dosing
  • Orthostatic hypotension, autonomic failure
  • Frequent toileting
  • Impaired mobility
  • Impaired vision
  • Inappropriate use of assistive devices or footwear
  • History of falls
  • Psychotropics, digoxin, type 1A anti-arrhythmic, diuretic (thiazides >loop diuretics).
  • Antihistamines/benzodiazepines (withdrawal has shown decrease in falls risk)
  • Antidepressants (tricyclics higher risk than SSRI, but SSRIs have risk as well, high level of phenytoin; low dose amitriptyline affects gait)
  • Drugs treating nocturia

Medical Consequences of Falls

Twenty percent to 30% of people who fall suffer moderate to severe injuries such as bruises, hip fractures, or head traumas. These injuries can make it hard to get around and limit independent living and can increase the risk of early death.

Most fractures among older adults are caused by falls; the most common fractures are of the spine, hip, forearm, leg, ankle, pelvis, upper arm, and hand. Those who fall, even those who are not injured, develop a fear of falling. This fear may cause them to limit their activities, leading to reduced mobility and physical fitness, and increasing their actual risk of falling (CDC, 2011d).

A review of thirty-three studies that looked at fear of falling (FOF) in community-dwelling older adults found that FOF is widespread with both those who have a history of falls and those who had not yet experienced a fall (Scheffer et al., 2008). The main risk factor for developing a fear of falling was a previous fall. Several studies showed fear of falling increasing with age and was more prevalent in women than men. Other risk factors for developing a fear of falling included:

  • Dizziness
  • Self-rated health status
  • Depression
  • Gait and balance disorders (Scheffer et al., 2008)

People may be unaware of the link between fractures and osteoporosis. Osteoporosis progresses without symptoms and in the most serious cases bones may become so fragile they break under the slightest strain. Falls are especially dangerous for people who are unaware that they have osteoporosis. If the patient and healthcare provider fail to connect a broken bone with osteoporosis, the chance is lost to make a diagnosis with a bone density test and begin a prevention or treatment program.

Falls and Traumatic Brain Injury

A traumatic brain injury (TBI) is caused by a bump or blow to the head that causes cognitive changes. People aged 75 and older have the highest rates of TBI-related hospitalizations. They also recover more slowly and die more often from TBI than younger people do. Falls are the most common cause of traumatic brain injuries (TBI); in the year 2000 TBI accounted for 46% of fatal falls among older adults (CDC, 2011d).

Symptoms of mild TBI include:

  • Low-grade headache that won’t go away
  • Having more trouble than usual remembering things, paying attention or concentrating, organizing daily tasks, or making decisions and solving problems
  • Slowness in thinking, speaking, acting, or reading
  • Getting lost or easily confused
  • Feeling tired all of the time, lack of energy or motivation
  • Change in sleep patternsleeping much longer than before, having trouble sleeping.
  • Loss of balance, feeling light-headed or dizzy
  • Increased sensitivity to sounds, lights, distractions
  • Blurred vision or eyes that tire easily
  • Loss of sense of taste or smell
  • Ringing in the ears
  • Change in sexual drive
  • Mood changes like feeling sad, anxious, or listless, or becoming easily irritated or angry for little or no reason (CDC, 2008c)

A person with moderate or severe TBI may show the symptoms of mild TBI but may also have:

  • A headache that gets worse or does not go away
  • Repeated vomiting or nausea
  • Convulsions or seizures
  • Inability to wake up from sleep
  • Dilation of one or both pupils
  • Slurred speech
  • Weakness or numbness in the arms or legs
  • Loss of coordination
  • Increased confusion, restlessness, or agitation (CDC, 2008c)

Older adults taking blood thinners (eg, warfarin) should be seen immediately by a healthcare provider if they have a bump or blow to the head, even if they do not have any of the symptoms listed above.

Fall Prevention Programs

Interventions can reduce fall risk through either exercise alone or by combining exercise with other risk-reduction approaches such as medication review and management, vision screening and correction, education, and safer living environments (CDC, 2008b).

Fall prevention programs should include education about fall risk factors and prevention strategies for older adults, families, and caregivers. Information can be communicated in an individual or a group setting. Exercise interventions can be offered in a community setting, at home with supervision, or in a program that combines group classes or one-on-one training with home-based exercise. Appropriate types of exercise that effectively reduce falls in older adults include:

  • Tai Chi
  • Strengthening exercises combined with balance training
  • Balance exercises

Because polypharmacy has been shown to increase the risk of fallsespecially in older adultsa medication review should be undertaken with medications adjusted or modified by a physician or nurse practitioner.

Vision should be assessed to determine if any visual changes are contributing to increased fall risk. Somatosensory changes should be assessed, particularly any sensory changes in the feet and legs (peripheral neuropathy, acute pain, arthritis, gout, swelling), or other sensory changes that may affect balance. A home safety assessment should be completed by a physical or occupational therapist with home modifications as needed.

Assistive Devices

Assistive devices can range from simple to complex and can improve function, increase independence, or simply make daily tasks easier. Some devices are designed to help with activities of daily living (ADLs) while others are designed to aid with balance and mobility.

Assistive devices designed to help with activities of daily living include those designed for cooking and eating, bathing and toileting, dressing, and grooming.

Cooking and eating aids include:

  • Rocker knives for one-handed cutting
  • Easy-grip silverware
  • Jar openers
  • Reaching tools
  • Plate guards
  • Pull-down shelves

Bedroom aids include:

  • Bedside commodes
  • Transfer boards
  • Night lights
  • Transfer poles and bedrails

Bathing and toileting aids include:

  • Hand-held shower head
  • Transfer bench for tub
  • Shower chair
  • Grab bars by toilet and in shower

Dressing aids include:

  • Zipper pulls and Velcro tabs
  • Elastic or non-tie shoelaces
  • Easy-to-pull sock and pantyhose aids

Grooming aids for personal hygiene needs include:

  • Long-handled combs and brushes
  • Electric toothbrushes
  • No-rinse shampoo and body wash

Mobility aids allow a person to move safely and independently both within the household and outdoors. They can also be of help for the caregiver if assistance is needed with mobility and transfers. Mobility aids include:

  • Gait beltsallow the caregiver to safely assist with transfers and gait
  • Lift vestsprovide a secure handhold for caregivers for transfers and walking
  • Caneswiden the base of support and provide proprioceptive feedback for balance
  • Crutchesprovide supportusually following an acute injury
  • Walkersprovide stability during ambulation

Wheelchairs

The design of commercial wheelchairs has changed surprisingly little since the first wheelchair was patented in the United States in 1869. The standard large-rear-wheel, small-front-wheel design is still the most common type of wheelchair despite years of innovative work by countless engineers and users throughout the world. In recent decades, mass production techniques involving lightweight materials such as aluminum and composite metals have changed the look of wheelchairsat least in industrialized countries.

A wheelchair is more than simply a chair with wheels. It is a dynamic wheeled mobility device that must fit the individual needs of the user. When ordering a wheelchair, consider the following:

  • The width and depth of the seat
  • The height of the back
  • The diameter of the wheels
  • The length of the footrests

Large companies such as Everest and Jennings, Invacare, and Quickie make inexpensive institutional wheelchairs with prices ranging from as low as $150 up to more than $400. The common feature about these inexpensive chairs is the lack of options for sizing and seating. The chairs are available in standard widths of 16” and 18” both of which are often too wide for the average adult userespecially older women. In ordering a wheelchair, you must specify the 16” width or the supply company will automatically deliver an 18” chair.

Under certain circumstances, Medicare will cover the cost of a wheelchair rental for home use. The coverage is usually only for low- to medium-cost wheelchairs and only those with a width of 16” or 18”. Medicare does not usually cover the cost of seat cushions or custom backs. Customized seating systems can be more than the cost of the wheelchair and are usually paid for by the client.

Seating

Construction of a Foam Cushion

image: foam cushion layers

Note the foam padding covered on top with a low-shear, breathable fabric. Courtesy of Sunrise Medical.

Layered foam pads can be effective pressure reduction cushions for wheelchairs. Jay (Sunrise Medical) cushions, for example, offer a variety of cost-effective, pressure-relief cushions made of layered foam and a low-shear, breathable fabric cover.

Construction of a Quality Gel Cushion

image: gel cushion layers

Note the gel padding alternating with layered foam and covered on top with a low-shear, breathable fabric. Courtesy of Sunrise Medical.

Gel cushions provide an extra measure of pressure relief, although poor-quality gel cushions tend to bottom outespecially if the gel is contained in one large bag or chamber rather than several smaller chambers. Poorly designed gel cushions are not only useless but they may also increase the risk of skin damage. Rubber or other non-breathable material covering a cushion tends to cause moisture buildup between the skin and the pad, which can contribute skin breakdown.

Good-quality gel cushions can redistribute weight and reduce skin shear. Because they use a combination of high-quality layered foam and gel packets they do not bottom out. Special covers designed to wick heat and moisture away from the skin further reduce the risk of pressure ulcers and skin breakdown.

Assistive Technology

Assistive technology is any kind of technology that can be used to enhance the functional independence of a person with a disability. Assistive technology can be anything from a simple (low-tech) device such as a magnifying glass, to a complex (high-tech) device such as a computerized communication system. It can be bigan automated van lift for a wheelchairor smalla grip attached to a pen or fork by Velcro. Assistive technology can also be a substitute, such as an augmentative communication device that provides vocal output for someone who is unable to communicate by voice.

Nutrition

Adequate nutrition is critical to health, function, and quality of life for people of all ages. For elders, nutrition is especially important because of their vulnerability to health problems and physical and cognitive impairments (AOA, 2011c).

Nutritional status has been shown to affect the age-related rate of functional decline for many organs and to be a determinant of changes in body composition associated with aging, such as loss of bone and lean body mass. Diet and nutrition have been related to the etiology of many chronic diseases affecting older people (eg, osteoporosis, atherosclerosis, diabetes, hypertension, and certain forms of cancer). These chronic diseases have been shown to cause physical and mental impairments in older people that threaten their independence, well-being, and quality of life (AOA, 2011c).

The Dietary Guidelines for Americans make seven broad dietary recommendations for people age 2 and older to help them choose food for a healthful diet:

  1. Eat a variety of foods.
  2. Maintain healthy weight.
  3. Choose a diet with plenty of vegetables, fruits, and grain products.
  4. Choose a diet low in fat, saturated fat, and cholesterol.
  5. Use sugars only in moderation.
  6. Use salt and sodium only in moderation.
  7. If you drink alcoholic beverages, do so in moderation. (AOA, 2011c)

For some of these recommendations, the Dietary Guidelines provide specific quantitative standards. Recommendations for a variety of foods are specified as a suggested number of daily servings from each of five basic food groups:

  • 3 to 5 servings of vegetables
  • 2 to 4 servings of fruits
  • 6 to 11 servings of breads, cereals, rice, and pasta
  • 2 to 3 servings of milk, yogurt, and cheese
  • 2 to 3 servings of meats, poultry, fish, dry beans and peas, eggs, and nuts (AOA, 2011c)

The Dietary Guidelines also state that total fat intake should not exceed 30% of food calories and saturated fat should be less that 10% of calories.

Protein

There is a reduction in total body protein with age. A decrease in skeletal muscle is the most noticeable manifestation of this change but there is also a reduction in other physiologic proteins such as organ tissue, blood components, and immune bodies, as well as declines in total body potassium and water. This contributes to impaired wound healing, loss of skin elasticity, and a decreased ability to fight infection (Chernoff, 2004).

Protein tissue accounts for 30% of whole-body protein turnover but that rate declines to 20% or less by age 70. The result of this phenomenon is that older adults require more protein/kilogram body weight than do younger adults (Chernoff, 2004).

Adequate dietary intake of protein may be more difficult for older adults to obtain. Dietary animal protein is the primary source of high biologic-value protein, iron, vitamin B-12, folic acid, biotin, and other essential nutrients. In fact, egg protein is the standard against which all other proteins are compared. Compared to other high-quality protein sources like meat, poultry, and seafood, eggs are the least expensive. The importance of dietary protein cannot be underestimated in the diets of older adults; inadequate protein intake contributes to a decrease in reserve capacity, increased skin fragility, decreased immune function, poorer healing, and longer recuperation from illness (Chernoff, 2004).

Vitamin D

Most people meet at least some of their vitamin D needs through food intake and exposure to sunlight. It is produced when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis. Vitamin D is a fat-soluble vitamin that is naturally present in very few foods, added to others, and available as a dietary supplement (ODS, 2011a).

Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany. It is also needed for bone growth and bone remodeling by osteoblasts and osteoclasts. Without sufficient vitamin D, bones can become thin, brittle, or misshapen. Together with calcium, vitamin D helps protect older adults from osteoporosis (ODS, 2011a).

Calcium

Calcium, the most abundant mineral in the body, is found in some foods, added to others, available as a dietary supplement, and present in some medicines (such as antacids). Calcium is required for vascular contraction and vasodilation, muscle function, nerve transmission, and intracellular signaling and hormonal secretion, though less than 1% of total body calcium is needed to support these critical metabolic functions. Serum calcium is very tightly regulated and does not fluctuate with changes in dietary intakes; the body uses bone tissue as a reservoir for and source of calcium to maintain constant concentrations of calcium in blood, muscle, and intercellular fluids (ODS, 2011b).

The remaining 99% of the body’s calcium supply is stored in the bones and teeth, where it supports their structure and function. Bone itself undergoes continuous remodeling, with constant resorption and deposition of calcium into new bone. The balance between bone resorption and deposition changes with age. Bone formation exceeds resorption in periods of growth in children and adolescents, whereas in early and middle adulthood the processes are relatively equal. In aging adults, particularly among postmenopausal women, bone breakdown exceeds formation, resulting in bone loss that increases the risk of osteoporosis over time (ODS, 2011b).

In 2010 the Institutes of Medicine (IOM) published a study that supported the importance of calcium and vitamin D in promoting bone health, but not in other conditions. According to the study, evidence is emerging that too much of these nutrients may be harmful. There is evidence that some post menopausal women may be taking in too much calcium, increasing the risk of kidney stones (IOM, 2011).

The IOM also concluded that most North Americans are getting enough vitamin D through sun exposure and foods. Too much vitamin D (above 10,000 IU per day) may cause kidney and tissue damage. However, people with dark-pigmented skin and older people living in institutions may be at risk for too little vitamin D (IOM, 2011).

Other Nutritional Supplements

Although the use of nutritional supplements is a common practice among older adults, randomized controlled trials have given mixed results regarding health benefits. The health benefits of folic acid, vitamins B-12 and B-6, and omega-3 fatty acids in older adults were studied. Supplements of the B vitamins folate, B-12, and B-6 were studied as related to prevention of a number of major age-related chronic diseases, including cardiovascular disease, stroke, cognitive decline, and cancer (PubMed.gov, 2010).

While there are some encouraging findings regarding stroke, depression, and macular degeneration (although in only one study in the latter case), little evidence has been found for the benefit of B vitamins in delaying cardiovascular disease or age-related cognitive changes. In the few cancer-related studies, the evidence of benefit is coupled with concerns about enhancing the growth of existing undiagnosed cancers (PubMed.gov, 2010).

In contrast, clear health benefits have been shown with modest increases in consumption of fatty fish or fish oil supplements, including a reduction in the risk of sudden cardiac death. In addition, there is evidence that high-dose fish oil supplements may lower serum triglyceride levels (PubMed.gov, 2010).

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